Provider Demographics
NPI:1588762538
Name:KRISHNAMOORTHI, KRISHNAMOORTHI (MD)
Entity type:Individual
Prefix:
First Name:KRISHNAMOORTHI
Middle Name:
Last Name:KRISHNAMOORTHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:K.
Other - Middle Name:
Other - Last Name:KRISHNAMOORTHI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2222 E ORANGEBURG AVE
Mailing Address - Street 2:SUITE A2
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3399
Mailing Address - Country:US
Mailing Address - Phone:209-622-0877
Mailing Address - Fax:209-874-3896
Practice Address - Street 1:324 F ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CA
Practice Address - Zip Code:95386-9013
Practice Address - Country:US
Practice Address - Phone:209-874-2321
Practice Address - Fax:209-874-3896
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70897207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104460Medicaid
CARHM53829HMedicaid
CAH24617Medicare UPIN
CAGR0104460Medicaid
CAZZZ04426ZMedicare ID - Type UnspecifiedGROUP ID
CARHM53829HMedicaid